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Genitourinary Issues During Spaceflight: a Review International Journal of Impotence Research (2005) 17, S64–S67 & 2005 Nature Publishing Group All rights reserved 0955-9930/05 $30.00 www.nature.com/ijir Genitourinary issues during spaceflight: a review JA Jones1*, R Jennings2, R Pietryzk3, N Ciftcioglu4 and P Stepaniak1 1NASA/Johnson Space Center, Houston, Texas, USA; 2University of Texas Medical Branch, Galveston, Texas, USA; 3M.S. Enterprise Advisory Services, Inc., Houston, Texas, USA; and 4Nanobac Life Sciences, Inc., Tampa, Florida, USA The genitourinary (GU) system is not uncommonly affected during previous spaceflights. GU issues that have been observed during spaceflight include urinary calculi, infections, retention, waste management, and reproductive. In-flight countermeasures for each of these issues are being developed to reduce the likelihood of adverse sequelae, due to GU issues during exploration-class spaceflight, to begin in 2018 with flights back to the Moon and on to Mars, according to the February 2004 Presendent’s Vision for US Space Exploration. With implementation of a robust counter- measures program, GU issues should not have a significant threat for mission impact during future spaceflights. International Journal of Impotence Research (2005) 17, S64–S67. doi:10.1038/sj.ijir.3901431 Keywords: spaceflight; genitourinary; reproduction; calculi, urinary retention Introduction Urinary calculi have been observed on one occasion in-flight and 14 occasions postflight. The one in-flight episode occurred in a Russian cosmo- There are many physiological effects and medical naut during a long-duration mission on the Salyut, issues that impact spaceflight missions. The genito- which nearly resulted in the crewmember being urinary (GU) system is not uncommonly affected medically evacuated due to inability to control his during spaceflight. In total, 10% of astronauts pain resulting from transient obstruction of the participating in Shuttle flights between 1981 and upper collecting system from a stone lodged in the 1998 (89 missions), which included 508 crew (439 distal ureter. In total, 11 US crewmembers have had men, 69 woman) over 4443 flight days, reported GU 14 urinary calculi following their spaceflights, all symptoms during flight. after missions less than 2 weeks in duration.1,2 Obviously, issues in the GU system can adversely Space travelers are at risk of urinary calculi due to affect the sexual health of the astronaut and there- the mobilization of calcium from the bone when fore have relevance to the focus of this special issue. exposed to prolonged microgravity. Due to tight regulation of calcium levels in the blood, the mobilized bone mineral during periods of un- weighting is excreted by the kidney, resulting in Issues of GU health increased concentration of calcium in the urine, and thereby increased solubility product of calcium salts GU issues during spaceflight can be categorized as like calcium oxalate. Long-duration spaceflight in follows: upper tract, lower tract, waste management, LEO (Low Earth Orbit) poses a greater risk for an and reproductive health. in-flight stone. Exploration Missions envisioned for the Moon and Mars will vary in mission length from a few weeks to perhaps 2–3 y. During these missions, the Upper tract transit phase from LEO to the planetary surface, traversing interplanetary space, will likely expose the crewmember to microgravity for extended The two previously observed conditions affecting periods, ranging from 4 to 6 days between the Earth the upper tracts during spaceflight are calculi and and Moon to 4–9 months, depending on the related obstruction. propulsion system and vehicle trajectory. After reaching the planetary surface, the crewmember’s musculoskeletal system will be under the influence *Correspondence: JA Jones, MD, NASA/Johnson Space of reduced or partial gravity. In the case of the Moon, Center, Houston, TX, USA. the gravity is approximately 1/6 of that of the Earth, Genitourinary issues during spaceflight JA Jones et al S65 while on Mars approximately 1/3 (0.38 g). It is not Diagnosis of UTI is aided on-orbit by urine chem- currently known how well ambulation in partial istry analysis strips (US) and an onboard urine gravity will maintain the musculoskeletal system analyzer (Russian). The combination of symptoms on its own; hence, the need for both transit phase plus positive findings of leukocyte esterase or and planetary surface operational countermeasures. nitrites on the urine strip make a diagnosis of UTI Also for Mars missions, a contingency management very likely. UTIs are easily treated with oral strategy has been developed at NASA/JSC for antibiotics flown in the ambulatory medical kit. endoscopic management of a ureteral calculus Countermeasures for UTIs include good perineal during spaceflight under ultrasound guidance.3 hygiene, clean urine collection system interface, A question currently under investigation at the adequate fluid hydration, and nominal time to void NASA/JSC by N Ciftcioglu and co-workers is after urge to void sensed (minimal delay in voiding). whether nanobacteria, which may have been found Occasionally, if the GU system is compromised by an in 1996 inside a Martian meteorite, can play a role in indwelling catheter or intermittent catheterization the pathogenesis of human calcific diseases such (ICC-Intermittent Clean Catheterization), then pro- as urinary and prostatic calculi. Nanobacteria or phylactic antisepsis or antibiotics can be used, for ‘nanoparticles’ have been found to reproduce more example, qHS nitrofurantoin while receiving ICC.8 vigorously in bioreactor microgravity simulators, and thus may pose a greater hazard in microgravity than on the ground, if their human pathogenecity is Retention. In the history of short-duration flight proven.4,5 on the Space Shuttle, there have been four cases of urinary retention requiring bladder catheterization. Another potential countermeasure, which that has The cause of these cases is again multifactorial, and been evaluated in ambulatory bedrest subjects, and extensively in clinical use for osteoporosis patients includes pharmacologic side effects (anticholiner- 6 gics such as antiemetics used to treat space motion is the bisphosphonate Aledronate. Bisphospho- sickness), delay in voiding (due to schedule and nates act by inhibiting the action of osteoclasts in mobilizing calcium from bone hydroxyapatite. waste control system availability), impaired sensor- ium, and possibly even microgravity itself (psycho- Bisphosphonates, like AG, have the potential to be logical and lack of gravity vector differences in protective of both the musculoskeletal and GU 9 systems by reducing the loss of bone mineral voiding technique). The added risks associated calcium. An ISS spaceflight study of the bispho- with long-duration flight for urinary retention are two-fold: (1) possibility of outlet obstruction from sphonates Aledronate and Zoledronic acid was recently approved by nonadvocate review team prostate or urethral infection/inflammation, and (2) reporting to NASA headquarters (Supplemental progression or recurrence of a pre-existing condi- tion, for example, a urethral stricture managed by Medical Objective Leblanc, JA Jones et al). It is dilatation, may have time to recur during a long- expected that bisphosphonates will be used syner- gistically with resistive exercise and perhaps AG if it duration flight. Screening should be performed for preflight conditions with potential for recurrence/ is operationally employed for exploration missions. progression and most likely excluded from long The last countermeasure that may be effective for reducing the risk of urinary calculi in flight is duration flight eligibility. currently under flight study on the Shuttle and ISS, Countermeasures for urinary retention include avoiding delays in voiding, selection criteria for is potassium citrate, in the form of Urocit-Kt (Mission Pharmacal).7 A mid-study interim analysis predisposing conditions as mentioned above, plus is being conducted by the investigators at the time of close monitoring of crew receiving anticholinergic medications, to include ICC if required to drain this manuscript preparation. urine from bladder before overdistension injury can occur. Lower tract Urinary waste Urinary tract infections (UTIs). UTIs have oc- curred on multiple occasions during spaceflight with multiple likely causative mechanisms. Cer- Urine is disposed of on-orbit via waste collection tainly, individual physical and mental stress, dehy- systems (WCS). Both the US and Russian toilets take dration and hygiene likely played a role during the advantage of negative pressure induced from fluid UTI acquired during Apollo 13. Other hygiene separation systems to effectively ‘acquire’ liquid issues such as collection devices and factors such waste from the crewmember (mild suction like a as delayed access to voiding and urinary stasis are weak shop vacuum cleaner). In both systems, a thought to also play a role in the UTI cases. One case funnel attached to a length of flexible tubing serves of prostatitis on the Salyut resulted in sepsis and as the point of interface between the WCS and the subsequently a medical evacuation of the patient. crewmember. International Journal of Impotence Research Genitourinary issues during spaceflight JA Jones et al S66 Reproductive health The known postflight effects of short duration (mean 9 day spaceflights) in LEO on all US astronauts, male and female, are as follows: Have had normal conception in both genders within 1
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